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Population Health, the Triple Aim, and the Health Effects of Social Services
December 24, 2016

Population Health, the Triple Aim, and the Health Effects of Social Services

How, or if, America will ultimately achieve better integration of medical and social services is an open question.

Accountable Health Communities: Learning by Doing

In January, 2016, CMS’ Center for Medicare and Medicaid Innovation announced its intent to test the effectiveness of different variations of what it termed the Accountable Health Communities model.7 According to CMS, the AHC model “is based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs.”8 Further, it “addresses a critical gap between clinical care and community services in the current healthcare delivery system by testing whether systematically identifying and addressing the health-related social needs of beneficiaries impacts total healthcare costs, improves health, and quality of care.”8 The AHC initiative is a direct outgrowth of Goal 5 of the CMS Quality Strategy (2015), which states that “successful efforts to improve social determinants of health and access to appropriate healthcare rely on deploying evidence-based interventions through strong partnerships between local healthcare providers, public health professionals, community and social services agencies, and individuals.”
The AHC initiative is ambitious and somewhat complicated. CMS plans to contract with up to 44 “bridge organizations” (a direct counterpart to Berwick et al’s “integrators”) for 5 years. These organizations can choose to pursue 1 of 3 tracks that have various levels of requirements: increasing beneficiary awareness of available community services; providing navigation services to assist beneficiaries in accessing services; and encouraging alignment of community partner organizations to assure services are available for beneficiaries. Track 3 would include all activities, while track 2 would contain only the first 2 and track 1 only screening and referral of beneficiaries to social services. Bridge organizations are prohibited from using their AHC program funds to directly purchase services.8
An extensive evaluation of the AHC effort is planned, which will involve randomization and/or matched comparison groups. Participants likely will vary not only in their “tracks,” but also in the types of beneficiaries they choose as a focus for social services (eg, those with diabetes), the details of the programs involved and the types of services they offer, and the characteristics of the “bridging” organizations.

The Work of Many Hands

While the AHC evaluation is underway, ideas about of how best to integrate social and health care services will continue to emerge. Looking forward, Bradley and Taylor observed in their Health Affairs blog that “integrating the work of health and social services will be long-term work requiring many hands.”9 Some have expressed hope that Medicare accountable care organizations will find it advantageous to play the integrator role, facilitating access to appropriate social services for their assigned beneficiaries, or even for residents of the larger communities in which they provide services.10,11 Others have expressed concerns that this presages a “takeover” of the social services enterprise by more powerful health care organizations.
There are examples of voluntary, community-level attempts to better integrate some types of social services with healthcare delivery (Accountable Care Communities and Accountable Health Communities)12;13 Related to this, the National Quality Forum has created an Action Guide (2014) to assist entities in coordinating efforts to improve population health.14
Proposals regarding how best to integrate medical and social services, and rebalance medical and social expenditures, have arisen from all points on the political spectrum. For instance, an affiliate of the conservative Manhattan Institute has proposed that Medicaid programs be given greater flexibility at the state level to allocate funds in ways that best improve the health of beneficiaries, including spending Medicaid dollars for social services where population health gains warrant it.15 Others have suggested more careful study of how some European countries coordinate medical and social services.16 (Perhaps it’s time to brush up on my Norwegian language skills.)
How, or if, America will ultimately achieve better integration of medical and social services— and whether significant improvements in population health occur as a consequence—is an open question. Even so, over the past 16 years the cumulative efforts of health services researchers have significantly contributed to a broader discussion of how to efficiently spend resources in the pursuit of better health outcomes. But, of course, more research is needed.

  1. Kindig D, Stoddart G. What is population health? [Research Support, Non-U.S. Gov't]. Am J Public Health. 2003:93(3);380-383.

  2. Kindig D. What Are We Talking About When We Talk About Population Health? Health Affairs Blog. Retrieved from

  3. Berwick DM, Nolan TW, WhittingtonJ. The triple aim: care, health, and cost. Health Aff (Millwood). 2000:27(3);759-769. doi: 10.1377/hlthaff.27.3.759

  4. Bradley EH, Elkins BR, Herrin J, Elbel B. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf. 2011:20(10);826-831. doi: 10.1136/bmjqs.2010.048363

  5. Taylor L, Coyle CE, Ndumele C, et al. Leveraging the Social Determinants of Health: What Works? Executive Summary. Yale Global Health Leadership Institute. Retrieved from

  6. Bradley EH, Canavan M, Rogan E, et al. Variation in health outcomes: the role of spending on social services, public health, and health care, 2000-09. Health Aff (Millwood), 2016:35(5);760-768. doi: 10.1377/hlthaff.2015.0814

  7. Alley DE, Asomugha CN, Conway PH, Sanghavi DM. Accountable health communities--addressing social needs through Medicare and Medicaid. N Engl J Med. 2016:374(1);8-11. doi: 10.1056/NEJMp1512532

  8. CMS. CMS Quality Strategy 2016. Retrieved from

  9. Bradley E, Taylor L. With the ACA Secure, It's Time To Focus On Social Determinants. Health Affairs Blog. Retrieved from

  10. Hacker K, Walker DK. Achieving population health in accountable care organizations. Am J Public Health. 2013:103(7);1163-1167. doi: 10.2105/AJPH.2013.301254

  11. Stoto MA. Population Health in the Affordable Care Act Era: Academy Health.

  12. National Association of Counties. Profiles of County Innovations in Health Care Delivery: Acountable Care Communities. NACO Healthy Counties. Retrieved from

  13. Corrigan JM, Fisher ES.. Accountable Health Communities: Insights From State Health Reform Initiatives. Retrieved from

  14. National Quality Forum. Multistakeholder Input on a National Priority: Improving Population Health by Working with Communities--Action Guide 1.0 (D. o. H. a. H. Services, Trans.).

  15. Cass O. Why Shouldn't Medicaid Money Treat Poverty Too? Bloomberg View. Retrieved from

  16. Bradley E, Taylor L. To Fix Health, Help the Poor. The New York Times. Retrieved from


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